NICOLE M. JACK (PA-C) – Physician Assistant, NPI 1083104137
Physician Assistant
Main info
Doctor Profile
Profile Insights
NPPES metrics only — not quality of care.
5,035 PHYSICIAN ASSISTANT in IL
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Provider Addresses for NICOLE M. JACK (PA-C)
West Reynolds Street, Pontiac, Livingston County, Illinois, 61764, United States
PONTIAC, IL 617649774
Phone: (815) 844-5343
Fax: (815) 844-5715
Mailing address matches the actual address.
NPPES updates history
No NPPES updates recorded for this provider.
Prescription Activity
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Open Payments (CMS)
No Open Payments data available for this provider.
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Medicare Enrollment & Revalidation
Source: CMS public data · Not endorsed by CMS ·
Educational use only—not medical, billing, or legal advice.
PECOS enrollment status
Participating (accepts Medicare assignment)
Enrollment effective: 2018-06-11
PECOS data refreshed: 2026-05-27
Medicare revalidation (CMS due date list)
Due date not assigned yet
CMS is tracking this Medicare enrollment for revalidation, but has not published a due date.
Enrollment records
1
Earliest due date
Not assigned (TBD)
CMS data updated
2026-06-01
Revalidation progress
- Medicare enrolled
- On CMS revalidation list
- Due date assigned
- Revalidate in PECOS
CMS enrollment records
| Enrollment ID | Type | Specialty | State | Due date |
|---|---|---|---|---|
| I20180611002269 | I | Physician Assistant | IL | TBD |
What to do next
- No action required while the due date shows TBD.
- Check the CMS Revalidation Lookup Tool periodically — CMS updates the list about every 60 days.
- Do not submit a revalidation application in PECOS until CMS publishes a concrete due date.
Prepare CMS-855 application → · Look up this NPI in PECOS → · Verify on CMS PECOS
Medicare Utilization (FFS)
Source: CMS public data · Not endorsed by CMS · Beneficiary counts under 11 are suppressed in source data ·
Educational use only—not medical, billing, or legal advice.
Top Medicare procedures (2023) · refreshed 2026-05-27
| HCPCS | Description | Services | Beneficiaries | Medicare allowed |
|---|---|---|---|---|
| 99214 | Established patient office or other outpatient visit, 30-39 minutes | 73 | 64 | $0 |
| 99213 | Established patient office or other outpatient visit, 20-29 minutes | 15 | 15 | $0 |
Insurance plans in this area (ZIP 61764)
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Group practice members
| Name | Specialty | State |
|---|---|---|
| Family Practice | NJ | |
| Nurse Practitioner | IL | |
| Nurse Practitioner | IL | |
| Vascular Surgery | IL | |
| Nurse Practitioner | IL | |
| Physician Assistant | IL | |
| - | IL | |
| Mental Health Counselor | IL | |
| - | IL | |
| Physician Assistant | IL |
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